Public Release: 

Annals of Family Medicine media tip sheet

November/December 2018 Annals of Family Medicine

American Academy of Family Physicians

Monday, November 12, 2018

Higher Primary Care Physician Continuity is Associated With Lower Costs

An ongoing patient-physician relationship is strongly associated with lower total health care costs and decreased hospitalization rates. Based on 2011 Medicare claims data for 1,448,952 beneficiaries receiving care from a nationally representative sample of 6,551 primary care physicians, researchers created physician-level claims-based measures of continuity of care utilizing four established methods. When tested, all four continuity measures were strongly correlated with health care expenditures and hospitalizations. Of the beneficiaries obtaining some care from primary care physicians in the sample, 1,178,369 (81 percent) obtained most of their care from these physicians. In analyses of one of the established continuity measures (the Bice-Boxerman Continuity of Care Index), adjusted expenditures for beneficiaries cared for by physicians in the highest continuity quintile were $6,920, 15 percent lower than those in the lowest quintile ($7,664). The odds of any hospitalization were 16 percent lower for those with the greatest continuity compared to the lowest levels. This study contributes to the overwhelming evidence of the value of continuity care, the authors suggest, and offers quality measures that can be used and prioritized in value-based payment models. Continuity of care is one of several core tenets of primary care that should be incorporated into official primary care measures, they state, as the American health care system shifts from paying for services to paying for value.

Higher Primary Care Physician Continuity is Associated With Lower Costs and Hospitalizations

Andrew Bazemore, MD, MPH, et al
Robert Graham Center for Policy Studies, Washington, DC

Editorial: Family Medicine Must Reclaim Its Focus on Continuity of Care

Research, including that of Bazemore et al (above), finds that continuity of care benefits patients, physicians and health care systems. Why then, asks editorialist John Frey, MD, is primary care moving away from continuity towards subspecialization, more episodic care, and limited scope of practice? As residency programs become increasingly fragmented, deemphasizing the key role of the family practice center and the community as the focus of learning, residents can narrow their careers without exploring broader options as they gain experience. Primary care, he states, must take action to reinstate continuity as "the essential and distinguishing value around which education is built," including a radical restructuring of residency education to avoid an ongoing drift towards narrower scope of practice. "To do nothing," writes Frey, "is a passive admission that either the fight is not worth it or that an educational system still primarily driven by productivity and hospital financial needs is 'good enough.'" He identifies consequences for physicians, who risk losing the genuine satisfaction of knowing and caring for patients and families over time; for patients, who face health care that is more costly for lower quality; and for the American health care system, which will eventually become economically unsustainable. He calls on family medicine to be part of the solution and not the problem.

Colluding With the Decline of Continuity

John J. Frey III, MD
University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

Failure to Discontinue Medications Can Contribute to Inappropriate Prescribing

The continuation of drugs that are not intended to be taken indefinitely is a substantial and common problem that could contribute to over-medication, particularly in the elderly. A new study of adults in and around Hamilton, Ontario, Canada (n=50,813), examined rates of what researchers have termed "legacy prescribing," i.e., medications that are not appropriately discontinued when their usefulness has diminished and when the risk of side-effects, interactions with other drugs, and ongoing costs remain. Specifically, the study calculated rates of legacy prescribing for three types of drugs: antidepressants (continuous prescribing of more than 15 months), bisphosphonates (continuous prescribing of more than 5.5 years), and proton pump inhibitors (continuous prescribing of more than15 months). The proportion of patients having a legacy prescription at some time during the study period was 46 percent (3,766 of 8,119) for antidepressants, 14 percent (228 of 1,592) for bisphosphonates, and 45 percent (2,885 of 6,414) for proton pump inhibitors. Until now, there has been little recognition of duration of medications as a source of inappropriate prescribing. The authors point out that prescribing systems are largely geared towards starting and continuing medicines; most have no controls to flag the end of an intermediate-term prescription, while routine re-prescribing systems and software features are common. These results are therefore not surprising and indicate a need for system-oriented change that encompasses prescribing systems, education and patient-pharmacist-physician communication on appropriate stopping of drug therapy. The authors also suggest that legacy prescribing could be explored as a quality measure to incentivize restraint in a system where there are currently few, if any, indicators of the adverse effects of too much medicine.

Legacy Drug-Prescribing Patterns in Primary Care

Dee Mangin, MBChB, DPH, et al
McMaster University, Hamilton, Ontario, Canada

Patients of Part-Time Clinicians May be Less Likely to Obtain Timely Appointments

Part-time clinicians may be less able to offer timely appointments to their patients than their full-time counterparts, according to a new study. Researchers examined the relationship between appointment backlog, panel size (the number of patients under a clinician's care), and clinician time in clinic. Among 114 primary care clinicians, less clinician time in clinic was independently associated with longer backlogs for appointments. Panel size, without adjusting for full-time equivalency and number of clinicians per site, had almost no correlation with access. These findings are particularly important in light of the increasing rate of clinicians who work part-time. The authors suggest that primary care practices consider, (1) establishing clinician teams to co-manage a patient panel and deliver more timely access to appointments, (2) establishing teams of clinicians and non-clinicians to reduce the need for traditional face-to-face clinician visits, and (3) reducing panel sizes which, the authors suggest, may be less feasible and perhaps less important than the presence of a clinician in the practice.

Panel Size, Clinician Time in Clinic, and Access to Appointments

David Margolius, MD, et al
MetroHealth System, Cleveland, Ohio

People Recently Released from Prison Are Less Likely to Receive a Doctor's Appointment

A history of recent imprisonment can affect an individual's access to primary care. In a study of access to care during the high-risk period following prison release, researchers phoned to request an initial appointment with all family physicians in British Columbia, Canada accepting new patients (n=339). Participants were sequentially assigned patient scenarios: male or female recently released from prison and male or female control group. Those who presented as having recently been released from prison were significantly less likely than controls to be offered an initial appointment with a primary care physician. The likelihood of obtaining an appointment was almost two times greater for controls compared to those who reported a recent prison history; 43 percent of those reporting recent release from prison obtained an appointment compared to 84 percent of controls. There was no difference in the likelihood of obtaining an appointment between male and female callers who reported recent release. Even in the context of a universal health care system, recent imprisonment may be a barrier to access to primary care, the authors state. They call for policies and programs to support people in gaining access to health care during the challenging transition from prison to the community.

Access to Primary Care for Persons Recently Released From Prison

Ruth Elwood Martin, MD MPH, et al
University of British Columbia, Vancouver, British Columbia, Canada

Joint Mobilization Plus Exercise Can Effectively Treat Knee Osteoarthritis

An intervention combining passive joint mobilization to realign the patellar (kneecap) position, along with exercise to maintain it, can reduce pain and improve function and quality in life in patients with knee osteoarthritis. In a randomized clinical trial, 208 primary care patients with knee osteoarthritis were assigned to either a patella mobilization therapy intervention group or a waiting list (control) group. In the intervention group, physicians mobilized the patellofemoral joint (the joint formed by the kneecap and femur) once every 2 months during three treatment sessions. Patients were placed in a side-lying position with the knee supported and slightly flexed to allow a vertical gravitational glide of the patella from a lateral to medial direction. Physicians also prescribed twice-daily home exercise to encourage continuous firing of the muscle and supervised patients to ensure that they performed the exercises correctly. The waiting list group received patella mobilization therapy after the study period. At 24 weeks, patients in the intervention group demonstrated significantly greater improvement in pain score than those in the waiting list group. Unlike conventional mobilization therapy involving multiple treatment sessions at intense frequency, this technique can easily be performed in primary care practice. The approximate time needed to learn and practice patella mobilization therapy is about one hour. Patient compliance with the study was high, suggesting that it is an acceptable treatment option. Next steps, the authors state, are to compare patella mobilization therapy with other active controls to further confirm its benefits and facilitate its deployment in real-world practice.

Clinic-Based Patellar Mobilization Therapy for Knee Osteoarthritis: A Randomized Clinical Trial

Regina Wing Shan Sit, MBBS, et al
The Jockey Club School of Public Health and Primary Care and The Chinese University of Hong Kong, Hong Kong, Hong Kong

Most, But Not All, Primary Care Clinicians Willing to Provide Routine Care for Transgender Patients

A new survey finds that most family medicine and general internal medicine clinicians are willing to provide routine care for transgender patients. In a survey of primary care clinicians in an integrated Midwest health system, 86 percent of respondents (n=140) were willing to provide routine care to transgender patients and 79 percent were willing to provide Pap tests to transgender men. Willingness to provide routine care decreased with age. Willingness to provide Pap tests was higher among family physicians, those who had met a transgender person, and those who measured lower on a transphobia scale. These findings, according to the authors, underscore the importance of integrating personal exposure to transgender individuals into medical education.

Primary Care Clinicians' Willingness to Care for Transgender Patients

Deirdre A. Shires, PhD, MSW, MPH, et al
Michigan State University, East Lansing, Michigan

Essay Offers Guidance on Communication With Transgender Patients

The increasing visibility of transgender people and others who do not conform to traditional gender norms challenges medical professionals to think about gender and communication in new ways. This is according to an essay from the National LGBT Health Education Center illustrating ways to interact respectfully and affirmatively with non-binary people (those who have a gender identity that is not exclusively girl/woman or boy/man) throughout the patient care experience. A small but growing body of research indicates that non-binary people experience high levels of societal victimization and discrimination and are misunderstood by clinicians. Using language that is inclusive of all gender identities can reduce these burdens and barriers, the authors suggest. This includes avoiding assumptions about patients' gender identities, asking for information about name and pronouns and using these consistently throughout the clinical setting, and describing anatomy and related terms with gender-inclusive language. These communication approaches, according to the essay, can help clinicians offer patient-centered care that moves beyond binary gender concepts.

Communicating With Patients Who Have Nonbinary Gender Identities

Alex S. Keuroghlian, MD, MPH, et al
The Fenway Institute, Boston, Massachusetts

Changes in Access to Insurance, Transportation or Residence Affect Access to Regular Medical Care

Access to a usual source of medical care is particularly important for older adults as they manage chronic medical conditions. According to a new national study, odds of losing a usual source of care are higher among older adults who have unmet transportation needs, who move to a new residence, or who report symptoms of depression. Odds of losing a usual source of care are lower for older adults with four or more chronic conditions and with supplemental or Medicaid insurance coverage. The study followed 7,609 participants in the National Health and Aging Trends Study, a nationally representative sample of Medicare beneficiaries age 65 years and older, for up to six years (2011-2016). Of the 95 percent of older adults who reported having a usual source of care in 2011, five percent subsequently did not. Most participants (60 percent) who reported loss of a usual source of care regained it by the next round of the study, however, those who did not regain it were more likely to continue to report lack of a usual source of care. The study results suggest that clinical as well as social factors are important in an older adult's ability to maintain a stable relationship with a clinician over time. The authors call for future work to assess how changes in health insurance, transportation and residence affect older adults' ability to experience a continuous source of care and the impact of that continuity on functional decline and hospital admissions.

Factors Associated With Loss of Usual Source of Care Among Older Adults

Stephanie K. Nothelle, MD, et al
Johns Hopkins University School of Medicine, Baltimore, Maryland

Performance Coaching for Clinicians Increases Treatment of Tobacco Dependence

Integrating "performance coaching" into the design and delivery of multi-component tobacco treatment interventions significantly increases rates of tobacco dependence treatment by primary care clinicians. In a cluster-randomized controlled trial, 15 primary care practices, including 166 primary care clinicians and 1,990 patients, were randomly assigned to one of two interventions. Both interventions helped teams implement the 5As model of treating tobacco use (Ask, Advise, Assess, Assist and Arrange) in the context of 10 best practices for delivering tobacco treatment. One intervention group also provided a 1.5-hour coaching session and an individualized performance report for family physicians and nurse practitioners. Both groups increased rates of tobacco dependence treatment delivery, however clinicians who received performance coaching had statistically higher rates of providing three elements of the 5 As: asking patients about their smoking status, assisting patients ready to quit by developing a quit plan, and arranging follow-up support. In sensitivity analysis, rates of tobacco cessation advice were greater among clinicians who attended a coaching session. There were no differences in tobacco cessation outcomes between the two groups. According to the authors, this study supports the integration of performance coaching into multi-component interventions to further increase the delivery of tobacco treatment, particularly among low-performing clinicians.

From Good to Great: The Role of Performance Coaching in Enhancing Tobacco-Dependence Treatment Rates

Sophia Papadakis, PhD, et al
University of Ottawa Heart Institute, Ottawa, Ontario, Canada

Most Older Adults Prefer Not to Discuss Life Expectancy

A majority of older adults do not wish to discuss life expectancy when presented with a hypothetical scenario on the topic. In a survey of communication around life expectancy, 878 adults age 65 years and older received a description of a hypothetical patient with limited life expectancy who is not imminently dying. Participants were asked, as the hypothetical patient, if they would like to talk with the doctor about how long they might live, if it was acceptable for the doctor to offer such discussion, whether they would want the doctor to discuss life expectancy with family or friends, and when life expectancy should be discussed. Fifty-nine percent of participants (n=515) did not want to discuss how long they might live in the presented scenario. Among these, 291 participants did not think that the doctor should offer discussion, and 450 participants did not want the doctor to discuss life expectancy with family or friends. As estimated life expectancy increased, fewer participants felt that it should be discussed. Fifty-six percent of participants (n=478) only wanted to discuss life expectancy if it were less than two years. Factors associated with wanting to discuss life expectancy included higher educational levels, belief that doctors can predict life expectancy, and past experiences with either a life-threatening illness or with discussing life expectancy of a loved one. Reporting that religion is important was associated with lower odds of choosing to discuss life expectancy. Overall, this research--the first national study to examine these questions--found that long-term life expectancy can be an important factor in health care decisions for older adults, but whether, when, and how to communicate with patients about it is not clear. The authors suggest that strategies to address this topic include assessing patient factors associated with willingness to discuss life expectancy and offering the discussion when closer to the patient's final year of life.

Older Adults' Preferences for Discussing Long-Term Life Expectancy: Results From a National Survey

Nancy L. Schoenborn, MD, MHS, et al
The Johns Hopkins University School of Medicine, Baltimore, Maryland

Pregnant Women Favor Urine Testing for Tobacco Cessation; Clinicians Express Concern

Up to one-third of female smokers with Medicaid deny tobacco use during pregnancy. A new study finds that, despite reservations, low-income patients have a favorable view of using urine testing, with consent, to promote smoking cessation during pregnancy. The study included 19 individual interviews and four focus groups with a total of 40 pregnant or postpartum women with Medicaid who smoked before or during pregnancy and 20 interviews with clinicians. Researchers collected patient urine samples using a test strip system which provides semi-quantitative detection of cotinine, a major nicotine byproduct. The majority of women interviewed (89 percent) strongly supported testing for tobacco use in pregnancy, but some feared the consequences of positive cotinine test results. Specifically, they were concerned about their clinician's reaction, potential violation of their privacy, and the involvement of government entities such as Child Protection Services. Women reported they would be more open to testing if clinicians described how the test could help them and their pregnancies. The majority of clinicians (more than 80 percent), were concerned that urine testing would have a negative impact on their relationship with patients. The authors call for research into the feasibility of consensual urine testing for tobacco use in the clinical setting. If increased testing leads to more patients getting support and counseling for tobacco cessation, they state, the benefits to public health could be enormous.

Prenatal Point-of-Care Tobacco Screening and Clinical Relationships

Aisha Bobb-Semple, MD, et al
Icahn School of Medicine at Mount Sinai, New York, New York

Nonapproved Pulse Oximeters May Effectively Rule Out Hypoxemia

In patients with oxygen saturation at or above 90 percent, peripheral pulse oximeters (devices widely used to measure oxygen saturation) have similar readings regardless of whether they are approved for medical use. This is according to a recent study of oxygen saturation in patients using one pulse oximeter approved for medical use by the US Food and Drug Administration compared to eight devices labeled "Not for Medical Use" and not FDA reviewed. Non-approved pulse oximeters are commonly sold in drugstores and over the Internet. Nineteen women and 41 men were studied and 669 data points (69-104 per oximeter) were obtained. There was no meaningful difference in displayed oxygen saturations between medical use and non-medical use pulse oximeters in the range from 90-99 percent. Non-medical use pulse oximeters, the authors suggest, may therefore be able to rule out hypoxemia, an abnormally low concentration of oxygen in the blood, in clinical settings. Because pulse oximeter measurements of oxygen saturation are less accurate below 90 percent, however, patient management decisions regarding oxygenation should be verified using a device intended for medical use whenever possible.

Clinical Interpretation of Peripheral Pulse Oximeters Labeled "Not for Medical Use"

Arlene J Hudson, MD, MA, et al
Uniformed Services University of the Health Sciences, Bethesda, Maryland

Is Empanelment the Future of Primary Care Training?

A family medicine resident makes a case for structuring primary care training around a "clinic first" curriculum where providing excellent outpatient clinical care and understanding the value of relationships "are the cornerstone of our learning." In a traditional family medicine residency, residents often rotate monthly from one clinical service to another in block rotations to build skills in different disciplines, including outpatient clinical skills. Outside of an outpatient skills block, resident time in clinic is often limited to one half-day per week. In contrast, the author describes a model in which residents are consistently present in clinic and empaneled with approximately 400 patients each that they care for from the beginning of their residency. Empanelment, the author states, has "allowed me to not only provide comprehensive care to my patients but also allowed me to develop competency and proficiency in managing their acute and chronic illnesses." Providing ongoing care has also helped him build relationships and understand the value of primary care. Residents need this type of experience, he states, in order "to build the primary care workforce of the future."

The Gift of Empanelment in a "Clinic First" Residency

Kumara Raja Sundar, MD
Kaiser Permanente of Washington, Seattle, Washington

Innovations in Primary Care

Innovations in Primary Care are brief one-page articles that describe novel innovations from health care's front lines. In this issue:

  • Improving Transitions from Hospital to Primary Care--A health systems genogram facilitates collaboration and communication between physicians, behavioral health professionals, and other health professionals when patients transition from the hospital to the outpatient setting.

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Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's website, http://www.annfammed.org.

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